“In July 2011, Mr Kehinde was an inpatient subject to an order under S.3 Mental Health Act…”
Dated 24 Apr 2024, from the coroner for East London. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 19 Jun 2024.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated24 Apr 2024
- Deadline19 Jun 2024
- Published on judiciary.uk30 Apr 2024
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North East London NHS Foundation TrustNamed in the report as “North East London Foundation Trust” | Response publishedPublished on judiciary.uk in April 2024. |
The coroner’s concerns
– 1. In July 2011, Mr Kehinde was an inpatient subject to an order under S.3 Mental Health Act 1983. On 2nd July 2011, Mr Kehinde was granted escorted S.17 leave to return home to collect belongings. Mr Kehinde left the ward in the company of a mental health nurse and they both travelled to a tattoo parlour. Mr Kehinde’s face was tattooed with a large permanent tattoo. No action was taken by the nurse to prevent this act occurring. The incident was not investigated as a serious incident by the Trust. Whereas the court does not suggest that a facial tattoo constitutes a factor that would likely cause a future death, concerns arise regarding; 6 The ability of staff authorised to supervise S.17 leave at identifying serious incidents that require meaningful intervention. The ability of the Trust to identify matters that require a full governance investigation.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2024-0218
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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